STORIES FROM OUR CCPES: A Saskatchewan view on lessons learned and current trends

Joy Dobson, MD, CCPE

Editor’s note: We asked CSPL members who have qualified as Canadian Certified Physician Leaders to tell us something about their “path” to leadership: what inspired them, how they succeeded, what they’ve learned. We hope their thoughts help you in your similar journey.

From 2008 to 2013, I served as the senior medical officer and VP medicine in the Regina Qu’Appelle health region. Almost 600 physicians, spread over a large geographic area, provided cradle-to grave tertiary care to

400,000 patients. My job was loosely described as “head coach of the medical staff.”

Learning to manage difficult behaviour

We had many wonderful examples of superb care from caring, committed physicians, but, as in any workplace, we also had examples of challenging behaviours. Managing that small minority taught me much — and saw me spending far too much time with lawyers.

We learned that the old school “fireside chat” is a poor tool if your goal is to address negative behaviour. A better path is using the format from Crucial Conversations or Crucial Confrontations and ensuring that interactions are both witnessed and documented. If your fireside chat was meant to pass on praise, again not a good forum. Shout that message from the rooftops!

We never thought that verbal reprimands were an especially effective way of coaching. Through an appeals process, we learned that verbal reprimands must also be delivered in writing, and, although it often felt like we were wasting our breath, rigorous attention to each step on the bumpy road of progressive discipline was necessary.

In contrast, a disciplinary hearing felt like detonating a bomb in a crowded room. By definition, this is an adversarial venue where the natural tendency is to drift toward a criminal standard of proof, possibly because of a focus on the impact on the individual physician’s career and financial health and the relative absence of the patient voice in the process. Panel selection and support was a logistical challenge, especially given the relatively small pool of colleagues to draw on. Given the stance of the Canadian Medical Protective Association on vigorous defense of physicians, discipline is a lengthy and costly process, with unpredictable outcomes, boxes of paperwork, and exhaustive appeals — rarely a path of choice.

Immediate suspension was the other tool at the heavy artillery end of the spectrum. This necessitated a board hearing to “set bail,” followed by a disciplinary hearing, followed by the same lengthy appeal processes.

We also saw added cost, risk, and harm for all parties — including patients and taxpayers — arising from parallel lawsuits. Civil actions are painful and tortuously lengthy procedures with few opportunities to expedite the process. In our experience, litigation plays out over 7–10 years, so be prepared from the outset for an endurance test.

The only other tool we had was negotiated dispute resolution, and this was heavily favoured. We used this approach repeatedly, even for high stakes interventions. Despite some limitations in terms of tools at our disposal, we usually could negotiate an effective position that protected patients and staff alike. But even this route had its challenges. After a resolution was signed and implemented, we could be forced to defend up to the Supreme Court of Canada level.

Lean management and process improvement

The current global trend in health care is to use both a lean management system and lean process improvement tools to drive change. The overall focus is to remove waste and so improve value, as defined by the customer. In Saskatchewan, Lean is synonymous with Patient First. Lean delivers better outcomes for patients, a better experience for both patients and providers (as it easier to reliably deliver the right service the right way), and lower costs in terms of both taxpayer dollars and risk of patient harm.

The aim of better care, better teams, and better value is not easily achieved overnight, so the work of a Lean transformation is not for the faint of heart. But this is the way we do things now in Saskatchewan — our culture and how we drive true transformational change. It means the quaternary aim of also ensuring joy in work is a realistic new target.

Quality improvement

The next trend is using not just medical science, but also quality improvement science. Our Saskatchewan Health Quality Council has been instrumental in teaching and spreading the use of measurement to support improvement. We know the basic principles: without standards there can be no improvement; you can’t improve what you don’t measure; what you measure is what you will improve; everything can be measured; and you must transparently measure over time to sustain improvement. An added bonus is that the objectivity of a graph helps truly define the problem and takes the emotion out of tackling it. Now, we see run charts on walls everywhere, from the individual hospital ward to the hallways of the ministry of health. As a scientist, I love this trend.

Of course, evidence-based medicine is a trend that now includes not just research on which therapies work best, but also feedback on how they work in the real world, where individual doctors treat individual patients. I said I love measurement, because knowing how you are doing is especially powerful for physicians. Show them data on how they compare with their peers on important measures of patient outcomes, and most performance issues will solve themselves. We saw this demonstrated repeatedly. Discussions with peers about reasons for variation typically led to practice changes and improvements for patients. This trend needs much greater spread to fully realize its power. Top

Leadership by physicians

You can’t get where you want to go without physicians being part of the structure. Co-leadership is now embedded at every level in Saskatchewan’s health system, and the silos are disappearing. Culture is what leaders do, so I know we are in great hands when I see the names on the new Saskatchewan Health Authority organizational chart. A strategic investment made by the Saskatchewan Medical Association to grow skilled physician leaders meant that there was a large pool of talent to call on to fill these roles.

The trend toward a strong talent management strategy for physicians is catching up to that used in other industries. The simplest strategy is to always have room for a star and never to be so desperate you take someone who is not a good fit. It is critical that you have a reliable way to select for talent. Locum contracts, for example, are a way for everyone to “test the waters” and determine where you are starting from. Then, you need good onboarding processes to ensure each individual’s continued growth and their long-term success.

Physicians typically have long careers and are often with your organization for many decades; so, your strategy must reflect this reality. You will be competing to retain talent, and your superstars will have many options. Don’t give them a reason to leave. That means you need a way to address toxic behaviours that might lead to a poisonous environment. Equally important is having leaders — right up to the board level — who have the courage and energy to tackle these problems, instill your organization’s values, and remain committed to quality care.

Like any organization, you will likely have problems with only a small percentage of physicians. This is a good trend: to treat physicians like the other members of the care team, following the principles of natural justice and progressive discipline.

But patient- and family-centred care may be the tool that underpins it all. The trend to truly put the patient first means their interests trump those of providers. It means their voice is the one we hear best and that our customers are happy with the value we provide. That is definitely a trend we all want — for ourselves and for our loved ones.